Preface to the First Edition

"Clinical forensic medicine"—a term now commonly used to refer to that branch of medicine involving an interaction among the law, the judiciary, and the police, and usually concerning living persons—is emerging as a specialty in its own right. There have been enormous developments in the subject in the last decade, with an increasing amount of published research that needs to be brought together in a handbook, such as A Physician's Guide to Clinical Forensic Medicine. The role of the health care professional in this field must be independent, professional, courteous, and nonjudgemental, as well as well-trained and informed. This is essential for the care of victims and suspects, for the criminal justice system, and for society as a whole.

As we enter the 21st century it is important that health care professionals are "forensically aware." Inadequate or incorrect diagnosis of a wound, for example, may have an effect on the clinical management of an individual, as well as a significant influence on any subsequent criminal investigation and court proceedings. A death in police custody resulting from failure to identify a vulnerable individual is an avoidable tragedy. Although training in clinical forensic medicine at the undergraduate level is variable, once qualified, every doctor will have contact with legal matters to a varying degree.

A Physician's Guide to Clinical Forensic Medicine concentrates on the clinical aspects of forensic medicine, as opposed to the pathological, by endeavoring to look at issues from fundamental principles, including recent research developments where appropriate. This volume is written primarily for physicians and nurses working in the field of clinical forensic medicine—forensic medical examiners, police surgeons, accident and emergency room physicians, pediatricians, gynecologists, and forensic and psychiatric nurses—but such other health care professionals as social workers and the police will also find the contents of use.

The history and development of clinical forensic medicine worldwide is outlined, with special focus being accorded the variable standards of care for detainees and victims. Because there are currently no international standards of training or practice, we have discussed fundamental principles of consent, confidentiality, note-keeping, and attendance at court.

The primary clinical forensic assessment of complainants and those suspected of sexual assault should only be conducted by those doctors and nurses who have acquired specialist knowledge, skills, and attitudes during both theoretical and practical training. All doctors should be able to accurately describe and record injuries, although the correct interpretation requires considerable skill and expertise, especially in the field of nonaccidental injury in children, where a multidisciplinary approach is required.

Avoidance of a death in police custody is a priority, as is the assessment of fitness-to-be-detained, which must include information on a detainee's general medical problems, as well as the identification of high-risk individuals, i.e., mental health and substance misuse problems. Deaths in custody include rapid unexplained death occurring during restraint and/or during excited delirium. The recent introduction of chemical crowd-control agents means that health professionals also need to be aware of the effects of the common agents, as well as the appropriate treatments.

Custodial interrogation is an essential part of criminal investigations. However, in recent years there have been a number of well-publicized miscarriages of justice in which the conviction depended on admissions made during interviews that were subsequently shown to be untrue. Recently, a working medical definition of fitness-to-be-interviewed has been developed, and it is now essential that detainees be assessed to determine whether they are at risk to provide unreliable information.

The increase in substance abuse means that detainees in police custody are often now seen exhibiting the complications of drug intoxication and withdrawal, medical conditions that need to be managed appropriately in the custodial environment. Furthermore, in the chapter on traffic medicine, not only are medical aspects of fitness-to-drive covered, but also provided is detailed information on the effects of alcohol and drugs on driving, as well as an assessment of impairment to drive.

In the appendices of A Physician's Guide to Clinical Forensic Medicine, the relevant ethical documents relating to police, nurses, and doctors are brought together, along with alcohol assessment questionnaires, the mini-mental state examination, and the role of appropriate adults; the management of head-injured detainees, including advice for the police; the Glasgow Coma Scale, and an example of a head injury warning card; guidance notes on US and UK statutory provisions governing access to health records; an alcohol/drugs impairment assessment form, along with a table outlining the peak effect, half-life, duration of action, and times for detection of common drugs.

Margaret M. Stark

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